Submission of this request in no way obligates the requester or applicant to open a health facility/agency. The information does allow the Division to track the number of proposed facilities, efficiently handle application requests and to eliminate unnecessary mailings of information packets. Please provide the requested information to the best of your knowledge. If a question is not applicable or is unknown at the time of request, please write “N/A” or “Unknown” where appropriate.

Thank you for your inquiry.

PLEASE NOTE: If you are an existing health facility or agency and have a portal account through cohfportal-egov.com, you must use the letter of intent available through your portal to report changes. Do not use this form.

* Required

Requestor Information

Facility/Agency information will be collected on the next page.

How would you like to receive your application packet? *

Email

Mail

Requestor Name *

Your answer

Email Address *

Your answer

Phone *

Your answer

Mailing Address (if requesting information be sent by mail)

Your answer

City, State

Your answer

Zip Code

Your answer

What type of information would you like?

Certification by Medicare or Medicaid is not available for all facility types. We can help you figure that out.